The Declaration of Hawaii issued by the World Psychiatric Association in 1977 and updated in 1983 in Vienna was initiated because of political abuse of psychiatry in some countries in the seventies. This led to a long process of investigation and concern within the domain of professional ethics and paved the ground for the Declaration of Madrid which was endorsed by the General Assembly of the World Psychiatric Association in Madrid in 1996. In its final form, the Declaration of Madrid [Espanol] includes seven general guidelines that focus on the aims of psychiatry namely to treat mentally ill patients, prevent mental illness, promote mental health and provide care and rehabilitation for mentally ill patients.
The Declaration prohibits abuse and that treatment be provided against a patient's will unless such treatment is necessary for the welfare and safety of the patient and others. Emphasis is placed on advising the patient or caregiver of all details of management, and informing him or her about confidentiality and the ethics of research. An appendix to the declaration includes guidelines on specific ethical issues in psychiatry (i.e., euthanasia, torture, the death penalty, sex selection and organ transplantation), as well as a summary of the 1991 United Nations resolutions on the rights of patients with mental illness. Issues of patient consent and autonomy are addressed in the Declaration of Madrid, and absolute commitment to patient welfare and condemnation of abuse by political institutions or other parties are evident in the declaration and its appendices.
In 1999 three other guidelines were endorsed addressing ethnic discrimiantion, genetic counselling and addressing the mass media. Further issues that are pending for discussion by the WPA Ethics Committee are the ethics of psychotherapy, the ethics of the conflict of interest in relationship with industry and the ethics of conflicts arising with third party payers. We believe that implementation of codes of ethics is frequently difficult because of the cultural and social setups in which the attempts at implementation are being made. These difficulties stem not only from interactions among individuals, families, and the community but also from the social position of the medical doctor and the hierarchical structure of the medical profession vis-à-vis the rest of the community. Religion and other beliefs also have an effect on the lives and behavior of people.
The development and implementation of ethical guidelines require attention to cultural sensitivity. For example, in Eastern cultures, social integration is emphasized more than autonomy; that is, the family, not the individual, is the unit of society. Dependence is more natural and infirmity is less alien in these cultures. When affiliation is more important than achievement, how one appears to others becomes vital and shame, rather than guilt, becomes a driving force. In the same manner, physical illness and somatic manifestations of psychological distress become more understood and acceptable and evoke a caring response. In some traditional cultures the collectivity of the community is valued rather than the individuality of its members. Decisions are made not at an individual level but on a familial, tribal or communal level, in the best perceived collective interest.
How can we adhere to our ethical guidelines and at the same time not disregard the local values and norms of our target population? How can we practice without showing disrespect or disregard for local values? On the other hand, how can we ensure that respect for the local culture does not become a pretext for bypassing ethical guidelines, to the detriment of the patients' rights?
The Declaration of Madrid and its specific guidelines are dynamic that it can address any challenges that may face psychiatrists from the ethical point of view. The WPA Ethics Committee welcome suggestions from Member Societies or individual Members to study any specific ethical issues facing the progressive development and changes in Medicine related to psychiatry.
A book published by American Psychiatric Press 2000, edited by Okasha et al "Ethics, Culture, and Psychiatry: International Perspectives" discusses the similarity and diversity of cultures in implementing the Declaration of Madrid and other ethical issues.
A forum on the Declaration of Madrid and Current Psychiatric Practice was published in Current Opinion in Psychiatry Vol. 12 No. Jan. 1999 where users and advocates views were addressed with the Ethics Committee of the WPA.